Acute extradural haematoma

Theory

Unlike an acute subdural haematoma, an acute extradural haematoma

is an intracerebral bleed at arterial pressure, meaning that it causes much more significant mass effects.

It occurs following a closed head injury and can affect any age group.

The most common pathology is bleeding from the middle meningeal artery from a fracture to the temporal or parietal bone. This causes bleeding between the dura mater and the bones of the skull.

This causes a rise in intracranial pressure and midline shift.

Death from tentorial herniation and coning can occur quickly, because the cranial cavity is a closed compartment and increasing pressure forces the pliable brain substance down through the foramen magnum.

Immediate intern management

  • If trauma situation/following a fall – ABCs and cervical spine immobilisation.
  • Targeted history and examination.
  • Suspect the diagnosis.

These patients only have a limited amount of time before catastrophic neurological deterioration. Urgent stabilisation and CT scanning is required.

  1. Sit patient to 30 degrees head up.
  2. Nil orally, oxygen by mask.
  3. Obtain IV access and commence gentle IV fluids.
  4. Measure and record Glasgow Coma Score (GCS).

If GCS falls to <8, patients can not protect airway and require intubation. Urgently notify senior staff/call Code Blue.

  1. Commence regular neurological observations:
    • every 15 minutes for two hours
    • every 30 minutes for two hours
    • every one hour for four hours.
  1. Organise urgent CT scan of brain.
  2. Notify parent registrar and surgical registrar.

Clinical features

History

Examination

Observation

Changing or deterioration in:

description

← acute extradural haematoma

Investigations

CT scan brain

Convex haematoma that does not cross suture lines of the skull bones

GCS – Glasgow Coma Score

 

Best observed ability

Score

Eyes

Open spontaneously

4

Open to voice

3

Open to pain

2

Closed

1

Verbal

Normal and appropriate

5

Speaks sentences but confused

4

Speaks words

3

Makes unintelligible sounds

2

Non-verbal

1

Motor

Obeys commands

6

Localises to pain

5

Withdraws to pain

4

Flexion to pain response

3

Extends to pain

2

No response

1

 

Definitive management

Urgent neurosurgical referral is required

Urgent neurosurgical decompression

Consider:

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